2018-05-10T09:43:28-05:00 2017-06-30 410746749 CLIFTONLARSONALLEN LLP 227 WEST TRADE STREET SUITE 800 CHARLOTTE NC 28202 990 2016-07-01 560611546 CHATHAM HOSPITAL INC CHAT 9197994000 PO BOX 649 SILER CITY NC 27344 JEFF LEGAY CFO 9197994000 2018-05-03 1 JOHN NORMAN P01506766 7049985200 2018-05-03 2016 2022-09-23 18:48:47Z ROBERT ENDERS PO BOX 649 SILER CITY NC 27344 37753276 0 X WWW.CHATHAMHOSPITAL.ORG X 1939 NC PROVIDES SHORT-TERM MEDICAL CARE ON AN INPATIENT AND OUTPATIENT BASIS. 15 11 268 18 378059 -26215 0 0 35972973 37080334 120586 130550 161944 528442 36255503 37739326 1630 1870 0 0 11392413 11816355 0 0 0 26149073 26735552 37543116 38553777 -1287613 -814451 39723334 38752645 33757680 30140589 5965654 8612056 TO PROVIDE EXCEPTIONAL HEALTH CARE SERVICES TO OUR COUNTY AND SURROUNDING COMMUNITIES IN COLLABORATION WITH OUR PHYSICIANS AND THE UNC HEALTH CARE SYSTEM. 0 0 33249543 1870 37080329 CHATHAM HOSPITAL, INC. IS A PRIVATE, NOT-FOR-PROFIT HEALTH CARE ORGANIZATION LOCATED IN SILER CITY, NORTH CAROLINA. THE FACILITY IS A 25-BED CRITICAL ACCESS HOSPITAL. THE HOSPITAL HAS A 75-YEAR HISTORY OF PROVIDING QUALITY HEALTH SERVICES. THE HOSPITAL PROVIDES COMPREHENSIVE CARE, INCLUDING EMERGENCY, GENERAL SURGERY, INTENSIVE CARE, LAB, CT, MRI, NUCLEAR MEDICINE, PHARMACY, CARIOPULMONARY, CARDIAC REHABILITATION, PHYSICIAL THERAPY, AND DIABETES EDUCATION ON ITS CAMPUS. 33249543 1 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 24 0 1 268 1 1 1 0 0 0 0 0 0 0 0 0 X 15 11 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X JEFF LEGAY 9197994000 475 PROGRESS BLVD SILER CITY NC 27344 MARY BECK DIRECTOR 2.00 X 0 0 0 WOODWARD BURGERT III MD DIRECTOR (AS OF 10/1/16) 2.00 58.00 X 0 185183 19254 CODY DEEN MD DIRECTOR 2.00 58.00 X 0 195605 19516 ETTA FOUSHEE DIRECTOR 2.00 X 0 0 0 MARK HALL DIRECTOR (AS OF 1/1/17) 2.00 X 0 0 0 BARRY HAYES DIRECTOR 2.00 X 0 0 0 MEL HURSTON DIRECTOR 2.00 58.00 X 0 326669 91633 JOHN LEWIS DIRECTOR (TERM ENDED 12/31/16) 2.00 58.00 X 0 791841 290557 TODD PETERSON DIRECTOR 2.00 X 0 0 0 WALTER PETTY DIRECTOR 2.00 X 0 0 0 DAVID POE DIRECTOR (AS OF 1/1/17) 2.00 X 0 0 0 PAUL POWELL DDS DIRECTOR 2.00 X 0 0 0 BARRY WILKIE DIRECTOR 2.00 X 0 0 0 MARK ZERINGUE MD DIRECTOR 2.00 X 0 0 0 BOB ENDERS CEO 60.00 X X 0 438377 97925 RAGHID BITAR MD DIRECTOR 2.00 X 0 0 0 JEFF LEGAY CFO (AS OF 9/1/16) 60.00 X 0 233341 16167 TAMMY NEEDHAM CNO 60.00 X 0 183961 32419 SHERLYNN POWELL PHARMACY DIRECTOR 60.00 X 142296 0 13791 142296 2354977 581262 1 0 1 0 CORE BUILDING COMPANY INC 1416 GAVIN STREET RALEIGH NC 27608 CONSTRUCTION 334123 LABCORP 458 S MAIN ST BURLINGTON NC 27215 LABORATORY 305348 ALLIANCE HEALTHCARE 100 BAY VIEW CIRCLE NEWPORT BEACH CA 92660 MEDICAL EQUIP 243194 RAO KOTHAPALLI MD PO BOX 767 SILER CITY NC 27344 PHYSICIAN 133257 UNIVERSAL PROTECTION SERVICES 3117 POPLARWOOD COURT 303 RALEIGH NC 27344 PROTECTION SERVICES 111535 6 PATIENT REVENUE 524113 36714980 36336921 378059 365354 365354 37080334 38068 38068 515015 0 515015 515015 515015 106432 13950 92482 92482 92482 MISCELLANEOUS 624100 13427 13427 13427 37739326 36336921 378059 1024346 X 1870 1870 9961045 6654734 3306311 97623 60775 36848 1176768 640910 535858 580919 361650 219269 9273626 8232744 1040882 3744 20 3724 588050 495983 92067 3538 3538 947073 947073 93352 27633 65719 1146265 1146265 1987511 1987511 298885 298885 BAD DEBT EXPENSE 5646431 5646431 HOME OFFICE ALLOCATION 4404902 4404902 PATIENT CARE SUPPLIES & 1687583 1687583 MINOR EQUIPMENT AND R&M 537028 537028 117564 117546 18 38553777 33249543 5304234 0 2381 2381 3184919 3087423 0 0 7498998 7603052 337240 382101 100632 533518 42998480 23420500 21466402 19577980 7101084 7565190 31678 1000 39723334 38752645 3536912 3512819 138738 201721 25782349 24854823 4299681 1571226 0 33757680 30140589 X 5965654 8612056 5965654 8612056 39723334 38752645 X -814451 15710 3445143 X X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 3845 3845 0 PART II-B, LINE 1: AS A MEMBER OF AHA AND NCHA, A PERCENTAGE OF THE MEMBERHSIP DUES ARE ATTRIBUTED TO LOBBYING. 402081 402081 18777078 7309556 11467522 2514503 1521609 992894 21304818 14589335 6715483 19577980 INVESTMENTS 524041 F RESTRICTED ASSETS 7041149 F 7565190 X 31948918 15710 -5646431 -5630721 37579639 159687 159687 37739326 31761081 0 31761081 6792696 6792696 38553777 PART X, LINE 2: THE HOSPITAL IS INCORPORATED AS A NONPROFIT ORGANIZATION UNDER THE LAWS OF THE STATE OF NORTH CAROLINA AND IS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT EXPENSE -5,646,431. PART XI, LINE 4B - OTHER ADJUSTMENTS: INVESTMENT INCOME 146,260. OTHER INCOME 13,427. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 5,646,431. INTEREST EXPENSE 1,146,265. 1 1 X 1 X 250.000000000000 0 1 1 1 0 1 1 2925043 2925043 0.08890 5577295 8993976 0 0.00000 8502338 8993976 2925043 0.08890 8502338 8993976 2925043 0.08890 1 2510525 1656947 12551161 14501183 -1950022 X 1 1 1 1 CHATHAM HOSPITAL 475 PROGRESS BLVD SILER CITY NC 27344 X X X X CHATHAM HOSPITAL 1 0 0 1 X X X X X X X X X 15 1 0 1 1 X SEE PART V X 1 15 1 SEE PART V 0 1 X 250.000000000000 X X X X X 1 1 X X X X 1 X SEE PART V X SEE PART V X SEE PART V X X X X X 1 0 X X X X 1 0 0 CHATHAM HOSPITAL PART V, SECTION B, LINE 5: THE FIRST STEP OF THE CHNA PROCESS WAS TO FORM A STEERING COMMITTEE. THE STEERING COMMITTEE GUIDES THE PROCESS, PROVIDING INPUT AND FEEDBACK TO THOSE WORKING ON EACH TASK. THE STEERING COMMITTEE IS ALSO RESPONSIBLE FOR PRIORITIZING HEALTH ISSUES BASED ON THE DATA COLLECTED AND REVIEWING THE FINAL CHNA REPORT. HEALTH DEPARTMENT STAFF WORKED WITH COMMUNITY PARTNERS TO RECRUIT MEMBERS OF THE STEERING COMMITTEE. CHATHAM HOSPITAL PART V, SECTION B, LINE 6B: CHATHAM COUNTY PUBLIC HEALTH DEPARTMENT CHATHAM HOSPITAL PART V, SECTION B, LINE 11: THE HOSPITAL HAS IDENTIFIED THE FOLLOWING AREAS AS THEIR TOP PRIORITIES:DECREASE OBESITYCHATHAM HOSPITAL, AS ONE OF THE TOP EMPLOYERS IN THE COUNTY WILL FOCUSON OBESITY / POPULATION HEALTH OF ITS EMPLOYEES THROUGH STRATEGIES THATENCOURAGE HEALTHY LIFESTYLES. STRATEGIES IDENTIFIED INCLUDE:- ADVOCATE FOR STAND-UP, ERGONOMIC OPTIONS FOR CHATHAM EMPLOYEES- PROVIDE HEALTHY EATING OPTIONS IN THE CHATHAM HOSPITAL CAFETERIA- COMMIT TO THE HEALTHY FOOD IN HEALTH CARE PLEDGE THROUGH THE HEALTH CARE WITHOUT HARM ORGANIZATION- PARTICIPATE IN THE CHATHAM HEALTH ALLIANCE SUBCOMMITTEE FOR REDUCING OBESITY- PARTICIPATE IN THE EXERCISE IS MEDICINEIMPROVE AND SUPPORT ACCESS TO MENTAL HEALTH SERVICESCHATHAM HOSPITAL WILL PROMOTE MENTAL HEALTH AND SUBSTANCE ABUSE TREATMENT AND COUNSELING SERVICES. CHATHAM HOSPITAL, IN PARTNERSHIP WITH THE LOCAL MANAGEMENT ENTITY (LME), CARDINAL INNOVATIONS, WILL CONTINUE TO FOCUS ON IMPROVING THE MENTAL HEALTH/SUBSTANCE ABUSE PATIENT EXPERIENCE BY PROVIDING THE RIGHT CARE, AT THE RIGHT PLACE, AT THE RIGHT TIME, BY THE RIGHT PROVIDER. STRATEGIES IDENTIFIED INCLUDE:- CONTINUE TO IMPROVE CHATHAM HOSPITAL RESOURCE OF PSYCHIATRIC TELEHEALTH- PARTICIPATE IN MENTAL HEALTH ROUNDTABLE THROUGH THE UNC HEALTH CARE SYSTEM- PARTICIPATE WITH COMMUNITY PARTNERS IN THE CHATHAM HEALTH ALLIANCE ACCESS TO MENTAL HEALTH CARE SUBCOMMITTEEIMPROVE ACCESS TO HEALTHCARE IN CHATHAM COUNTYCHATHAM HOSPITAL WILL COLLABORATE WITH STRATEGIC PARTNERS TO PROMOTE, PROVIDE AND ASSIST IN COORDINATION OF HEALTHCARE SERVICES. STRATEGIES IDENTIFIED INCLUDE:- CONTINUE CHATHAM HOSPITAL CHARITY CARE PROGRAM - CONTINUE CHATHAM HOSPITAL CARDIAC AND PULMONARYREHAB SCHOLARSHIP PROGRAM - SUPPORT AND PROMOTE RECENT CHATHAM HOSPITAL ADDITIONAL SERVICES PROVIDED BY SPECIALISTS IN THE CHATHAM PARK MEDICAL OFFICE (GENERAL SURGERY, ORTHOPEDICS, OPHTHALMOLOGY, CARDIOLOGY, ENT, IMAGING, PHYSICAL THERAPY) - PARTICIPATE WITH COMMUNITY PARTNERS IN THE CHATHAM HEALTH ALLIANCE SUBCOMMITTEE - ACCESS TO HEALTHCARETHE CHATHAM CHNA SIP TASK FORCE WILL MAKE ADJUSTMENTS ALONG THE WAY ENABLING COLLABORATION WITH COMMUNITY PARTNERS WHILE RESPONDING TO LOCAL CONDITIONS AND CHANGES IN COMMUNITY PRIORITIES AND LEADERSHIP. THE TASK FORCE WILL EVALUATE PROGRESS AT THE END OF EACH CALENDAR YEAR AND MODIFY THE PLAN ACCORDINGLY. SCHEDULE H, PART V, SECTION B, LINE 7A HTTPS://WWW.CHATHAMHOSPITAL.ORG/CH/ABOUT-US/COMUNITY-HEALTH-NEEDS-ASSESSEMENT/ SCHEDULE H, PART V, SECTION B, LINE 10A HTTPS://WWW.CHATHAMHOSPITAL.ORG/CH/ABOUT-US/COMUNITY-HEALTH-NEEDS-ASSESSEMENT/ SCHEDULE H, PART V, SECTION B, LINES 16A-C HTTPS://WWW.UNCMEDICALCENTER.ORG/UNCMC/PATIENTS-VISITORS/BILLING/FINANCIAL-ASSISTANCE-PROGRAMS/ 2 1 - CHATHAM HOSPITAL MEDICAL OFFICE BUILDING 163 MEDICAL PARK DRIVE SILER CITY NC 27344 CARDIAC REHABILITATION, DIABETES EDUCATION, PT/OT, AND OTHER ADMIN FUNCTIONS 2 - CHATHAM REHAB SERVICES AT PITTSBORO 75 FREEDOM PKWY STE E PITTSBORO NC 27312 REHABILITATION SERVICES PART I, LINE 3C: CHARITY CARE IS AVAILABLE FOR NORTH CAROLINA RESIDENTS WHO HAVE A HOUSEHOLD INCOME AT OR LESS THAN 250% OF THE FEDERAL POVERTY GUIDELINES FOR THEIR FAMILY SIZE. A COMPLETE APPLICATION WITH SUPPORTING DOCUMENTATION OF INCOME IS PROVIDED FOR A FINAL DETERMINATION TO BE MADE. CHARITY CARE IS A BENEFIT WHERE 100% OF THE PATIENTS BALANCE WILL BE WRITTEN OFF EXCEPT FOR CERTAIN LIMITATIONS SUCH AS ELECTIVE, NON-MEDICALLY NECESSARY SERVICES AND THOSE BALANCES COVERED BY OTHER EXTERNAL FUNDING SOURCES.FPG IS USED FOR CHARITY CARE/FREE CARE. FOR SELF PAY, PROVIDE STRAIGHT 40% DISCOUNT ON CHARGES. PART I, LINE 7: AMOUNTS SHOWN IN PART I, LINE 7, COLUMN C WERE COMPUTED USING THE COST-TO-CHARGE RATIO WORKSHEET (WORKSHEET 2) FROM THE IRS INSTRUCTIONS FOR SCHEDULE H. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 5,646,431. PART II, COMMUNITY BUILDING ACTIVITIES: CHATHAM HOSPITAL STRIVES TO IMPROVE EMERGENCY CARE FOR KIDS BY INCREASING MEDICATION SAFETY. ALSO, THE HOSPITAL HAS A DIABETES SELF-MANAGEMENT PROGRAM FOR INDIVIDUALS WITH DIABETES WITHIN THE COMMUNITY. CHATHAM HOSPITAL PARTICIPATES IN NUMEROUS COMMUNITY HEALTH FAIRS, PARTNERS WITH OTHER COMMUNITY LEADERS IN ADDRESSING HEALTH RELATED MATERS, PARTICIPATES IN COMMUNITY FUND RAISING EVENTS. PART III, LINE 2: THE COST-TO-CHARGE RATIO WAS APPLIED AGAINST GROSS BAD DEBT CHARGES TO ARRIVE AT THE ESTIMATED COST OF BAD DEBT EXPENSES. PART III, LINE 3: THE AMOUNTS ESTIMATED AS BAD DEBT ATTRIBUTABLE TO PATIENTS UNDER THE FINANCIAL ASSISTANCE POLICY WERE CALCULATED BY DETERMINING WHAT AMOUNT OF GROSS BAD DEBT CHARGES WERE ATTRIBUTABLE TO UNINSURED PATIENTS AND APPLYING THE COST-TO-CHARGE RATIO. PART III, LINE 4: NET PATIENT SERVICE REVENUE IS RECORDED AT ESTABLISHED RATES WHEN SERVICES ARE PROVIDED WITH CONTRACTUAL ADJUSTMENTS, ESTIMATED BAD DEBT EXPENSES, AND SERVICES QUALIFYING AS CHARITY CARE DEDUCTED TO ARRIVE AT NET PATIENT SERVICE REVENUE. CONTRACTUAL ADJUSTMENTS ARISE UNDER REIMBURSEMENT AGREEMENTS WITH CERTAIN INSURANCE CARRIERS, HEALTH MAINTENANCE ORGANIZATIONS AND PREFERRED PROVIDER ORGANIZATIONS, WHICH PROVIDE FOR PAYMENTS THAT ARE GENERALLY LESS THAN ESTABLISHED BILLING RATES. SPECIFIC PATIENT BALANCES ARE WRITTEN OFF AT THE TIME THEY ARE DETERMINED TO BE UNCOLLECTIBLE. PART III, LINE 8: AS A CRITICAL ACCESS HOSPITAL, THE DIFFERENCE BETWEEN REVENUE RECEIVED FROM MEDICARE AND THE MEDICARE ALLOWABLE COST IS THE AMOUNT DUE FROM THE PATIENTS IN THE FORM OF CO-PAYMENTS, CO-INSURANCE AND DEDUCTIBLES. THE PATIENT AMOUNTS THAT ARE NOT COLLECTED END UP AS BAD DEBTS WHICH ARE PARTIALLY RECOVERABLE ON FUTURE COST REPORTS. PART III, LINE 9B: POLICY DOES CONTAIN PROVISIONS ON THE COLLECTION PRACTICES TO BE FOLLOWED FOR PATIENTS WHO ARE KNOWN TO QUALIFY FOR CHARITY CARE PART VI, LINE 2: LESS THAN 20% OF OUR COUNTYS RESIDENTS LIVE IN INCORPORATED TOWNS. THE COUNTY HAS ABOUT 85 RESIDENTS PER SQUARE MILE, WHICH REFLECTS ITS GENERALLY RURAL NATURE. A CRITICAL ACCESS HOSPITAL IS ESSENTIAL FOR A RURAL COMMUNITY SUCH AS THIS.CHATHAM HOSPITAL ADDRESSES THE COMMUNITY'S EMERGENCY HEALTH NEEDS BY PROVIDING AROUND-THE-CLOCK EMERGENCY SERVICES TO MORE THAN 1,000 PATIENTS EACH MONTH. OUR 5,500-SQUARE FOOT EMERGENCY ROOM IS NEWLY RENOVATED AND EQUIPPED WITH THE ADVANCED DIAGNOSTIC AND MONITORING EQUIPMENT REQUIRED TO DELIVER EXCELLENT CARE.CHATHAM HOSPITAL STRIVES TO IMPROVE EMERGENCY CARE FOR KIDS BY INCREASING MEDICATION SAFETY. ALSO, THE HOSPITAL HAS A DIABETES SELF-MANAGEMENT PROGRAM FOR INDIVIDUALS WITH DIABETES WITHIN THE COMMUNITY. PART VI, LINE 3: NOTICES OF PATIENT FINANCIAL PROGRAMS ARE POSTED IN SERVICE AREAS, AND BROCHURES ARE AVAILABLE DESCRIBING THE PROGRAMS AND PHONE NUMBERS FOR QUESTIONS OR TO REQUEST APPLICATIONS. FINANCIAL COUNSELORS ARE LOCATED IN SERVICE AREAS FOR DISCUSSIONS REGARDING FUNDING SOURCES, INCLUDING CHARITY CARE. AND, SELF PAY PATIENT ACCOUNTS ARE AUTOMATICALLY ROUTED TO MEDICAID ASSISTANCE COUNSELORS FOR REVIEW OF ELIGIBILITY POTENTIAL FOR MEDICAID. REGISTRATION COVERS THE CHARITY PROGRAM WITH PATIENTS DURING REGISTRATION AND GIVES CHARITY APPLICATIONS TO THOSE WHO DON'T HAVE INSURANCE OR WHO MEET CERTAIN CRITERIA. REGISTRATION ALSO INFORMS PATIENTS THAT PATIENT FINANCIAL SERVICES IS AVAILABLE TO PATIENTS WHO WISH TO DISCUSS PAYMENT OPTIONS. PART VI, LINE 4: POPULATION INFORMATION: THE OFFICIAL 2010 CENSUS PLACES OUR 2010 POPULATION AT 63,505, AN INCREASE OF 28.74% SINCE 2000. THE STATE AVERAGE GROWTH FOR THIS DECADE WAS 18.5%. LESS THAN 20% OF OUR COUNTY'S RESIDENTS LIVE IN INCORPORATED TOWNS. THE COUNTY HAS ABOUT 85 RESIDENTS PER SQUARE MILE, WHICH REFLECTS ITS GENERALLY RURAL NATURE. ETHNIC/RACIAL DIVERSITY: THE OVERALL, RACIAL/ETHNIC COMPOSITION OF CHATHAM COUNTY IS: 71% WHITE, 13% AFRICAN AMERICAN, 12% HISPANIC, 2% ASIAN AND 2% OTHER.AGE: THE 2009 ESTIMATED MEDIAN AGE FOR CHATHAM COUNTY RESIDENTS IS 42, UP FROM 38.7 IN 2007 AND ABOVE THE STATE AVERAGE. THE GREATEST PERCENTAGE OF OUR POPULATION (54%) IS IN THE RANGE OF 20 TO 60 YEARS OLD, AND 21.9% ARE AGE 60 OR OLDER. INCOME AND POVERTY: THE ESTIMATED MEDIAN HOUSEHOLD INCOME FOR CHATHAM COUNTY IN 2008 WAS $46,574, A SIGNIFICANT DROP FROM $51,794 IN 2007, BUT STILL RANKS US 8TH IN THE STATE PER CAPITA INCOME FOR 2008 WAS $43,894, WHICH RANKS THIRD OUT OF THE 100 COUNTIES. THE PERCENTAGE OF INDIVIDUALS LIVING IN POVERTY IN 2008 WAS ESTIMATED AT 10.3%, LOWER THAN THE STATE AVERAGE OF 14.6%, BUT STILL SIGNIFICANT. THIS POINTS OUT THE CHALLENGES OF A COUNTY WITH RESIDENTS AT EXTREME ENDS OF THE INCOME SPECTRUM. PART VI, LINE 5: CHATHAM HOSPITAL STRIVES TO FURTHER IT EXEMPT PURPOSES BY PARTNERING IN THE COMMUNITY TO ASSESS HEALTH NEEDS AND TO HELP DEVELOP STRATEGIES TO FULLFUL THOSE NEEDS. CHATHAM HOSPITAL IS WELL ENGAGED IN THE COMMUNITY THROUGH JOINT EFFORTS WITH OTHER ORGANIZATIONS, COMMUNITY OUTREACH THROUGH EDUCATION AND HEALTH FAIRS, DIRECTLY CONTRIBUTING TO FUNDRAISING EFFORTS, WORKING TO QUALIFY PATIENTS FOR EITHER INSURANCE OR CHARITY CARE AND IF NOT, PROVIDING DISCOUNTS TO HEALTH SERVICES. PART VI, LINE 6: CHATHAM HOSPITAL AND UNC HEALTH CARE ARE PARTNERING TO BRING NATIONALLY-RECOGNIZED HEALTH CARE TO CHATHAM COUNTY. OUR PARTNERSHIP MEANS YOU'LL CONTINUE TO HAVE ACCESS TO ADVANCED HEALTH CARE CLOSE TO HOME, WITH THE PERSONAL TOUCH YOU'VE COME TO EXPECT FROM US. PART VI, LINE 7, REPORTS FILED WITH STATES NC 1 X X X X X 0 1 0 0 0 1 1 0 0 WOODWARD BURGERT III MD DIRECTOR (AS OF 10/1/16) 0 165681 0 16264 0 3238 0 7222 0 12032 0 204437 0 0 CODY DEEN MD DIRECTOR 0 190036 0 0 0 5569 0 11445 0 8071 0 215121 0 0 MEL HURSTON DIRECTOR 0 234299 0 44801 0 47569 0 75592 0 16041 0 418302 0 0 JOHN LEWIS DIRECTOR (TERM ENDED 12/31/16) 0 543926 0 94059 0 153856 0 270505 0 20052 0 1082398 0 151068 BOB ENDERS CEO 0 318229 0 63523 0 56625 0 77914 0 20011 0 536302 0 0 JEFF LEGAY CFO (AS OF 9/1/16) 0 195829 0 36746 0 766 0 7087 0 9080 0 249508 0 0 TAMMY NEEDHAM CNO 0 148356 0 35517 0 88 0 26839 0 5580 0 216380 0 0 SHERLYNN POWELL PHARMACY DIRECTOR 107210 0 11086 0 24000 0 4326 0 9465 0 156087 0 0 0 PART I, LINE 4B JOHN LEWIS - $151,068 JOHN LEWIS PARTICIPATED IN A NON-QUALIFIED SUPPLEMENTAL RETIREMENT PLAN FUNDED AND CONTROLLED BY A RELATED ORGANIZATION, UNC HCS, AND RECEIVED DISTRIBUTIONS TOTALING $151,086. HE ALSO EARNED COMPENSATION UNDER THIS PLAN TOTALING $159,911, WHICH IS PAYABLE IN THE FUTURE. PART I, LINE 6 EMPLOYEES IN MANAGERIAL ROLES PARTICIPATE IN AN ANNUAL INCENTIVE COMPENSATION PLAN. THE COMPENSATION EARNED UNDER THIS PLAN IS BASED PARTLY ON THE EARNINGS OF CHATHAM HOSPITAL AND THE UNC HEALTH CARE SYSTEM. A NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 657905ES0 2007-02-08 30540000 FHA INSURED MORTGAGE REVENUE BONDS 0 0 0 A 6450000 30540000 2303775 622810 329280 28221503 2008 1 0 1 1 A 0 0 0 0 0 0 1 A 1 0 0 0 0 0 A 1 FORM 990, PART VI, SECTION A, LINE 6 SEE RESPONSE TO QUESTION 7A. FORM 990, PART VI, SECTION A, LINE 7A IN ADDITION TO SUCH POWERS AND RIGHTS AS ARE VESTED IN IT BY LAW, THE AMENDED AND RESTATED ARTICLES OF INCORPORATION OF THE CORPORATION OR THE AMENDED AND RESTATED BYLAWS, THE MEMBER ("UNCHCS") SHALL HAVE THE FOLLOWING POWERS: (A) THE POWER TO APPOINT THE CHAIRMAN OF THE BOARD, VICE CHAIRMAN, PRESIDENT, EXECUTIVE VICE PRESIDENTS, SECRETARY/TREASURER AND OTHER CORPORATE OFFICERS OF THE CORPORATION; (B) THE POWER TO APPOINT INDIVIDUAL MEMBERS OF THE CORPORATION'S BOARD OF TRUSTEES; (C) THE POWER TO ESTABLISH AND MAINTAIN QUALITY, SERVICE DELIVERY, AND FINANCIAL STANDARDS TO BE OBSERVED BY ALL MEMBERS OF UNCHCS, INCLUDING THE CORPORATION; (D) THE POWER TO ESTABLISH A SCHEDULE OF COST-BASED ASSESSMENTS PAYABLE BY PROVIDER COMPONENTS OF UNCHCS FOR THE SUPPORT OF THAT PORTION OF ITS OPERATING BUDGET ATTRIBUTABLE TO UNCHCS-WIDE ADMINISTRATION AND INITIATIVES AND REFLECTING OPERATING ENTITY PERFORMANCE; (E) THE POWER TO NEGOTIATE, DEVELOP, AND APPROVE ALL MANAGED CARE PRODUCTS AND CONTRACTS FOR THE CORPORATION; (F) THE POWER TO APPROVE (I) THE CORPORATION'S NAME, (II) CAPITAL AND OPERATING BUDGETS OF THE CORPORATION, AND (III) NON-BUDGETED MATERIAL EXPENDITURES OF THE CORPORATION (AS "MATERIAL" IS ESTABLISHED BY THE MEMBER FROM TIME TO TIME), PROVIDED THAT ONLY THE BOARD OF TRUSTEES SHALL HAVE THE AUTHORITY TO INITIATE A CHANGE IN THE NAME OF THE CORPORATION OF THE HOSPITAL, WHICH SHALL BE SUBJECT TO FINAL APPROVAL BY UNCHCS; AND (G) OTHER POWERS MUTUALLY AGREED TO BY UNCHCS AND THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7B SEE RESPONSE TO QUESTION 7A. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 WAS REVIEWED PRIOR TO FILING BY THE PRESIDENT AND CFO OF THE HOSPITAL. IN ADDITION, IT WAS MADE AVAILABLE TO EVERY MEMBER OF THE GOVERNING BODY BEFORE IT WAS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST STATEMENTS ARE COMPLETED BY THE BOARD MEMBERS ANNUALLY TO BE REVIEWED BY THE HOSPITAL PRESIDENT. THE CHATHAM HOSPITAL CONFLICT OF INTEREST POLICY OUTLINES THE PROCESS TO BE FOLLOWED IN DETERMINING THE EXISTENCE OF A POTENTIAL CONFLICT, AND HOW TO ADDRESS THE SITUATION. FORM 990, PART VI, SECTION B, LINE 15 EFFECTIVE AUGUST 1, 2006, THE HOSPITAL ENTERED INTO A FIVE-YEAR CONTRACT WITH UNC HOSPITAL (UNCH) TO PROVIDE A CEO AND CFO TO MANAGE THE DAY-TO-DAY OPERATIONS OF THE HOSPITAL. THE PRESIDENT OF CHATHAM HOSPITAL REPORTS MONTHLY TO THE PRESIDENT OF UNCH, DISCUSSING SURVEYS OF COMPENSATION DATA AND PLANNED RANGES OF SALARY OFFERS FOR EMPLOYEES OF CHATHAM. WITH INPUT FROM THE MANAGEMENT OF UNCH, THE PRESIDENT OF CHATHAM HOSPITAL MAKES THE FINAL DECISION ON SALARIES, WITH THE EXCEPTION OF HIS/HER OWN, WHICH IS SET BY THE PRESIDENT OF UNCH WITH INPUT FROM THE UNCH'S MANAGMENT TEAM. FORM 990, PART VI, SECTION C, LINE 19 PHOTOCOPIES OF THE FORM 1023 AND RECENT COPIES OF THE FORM 990 ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. IN ADDITION, RECENT COPIES OF FORM 990 ARE AVAILABLE ONLINE AT WWW.GUIDESTAR.ORG. FORM 990, PART IX, LINE 11G OTHER FEES: PROGRAM SERVICE EXPENSES 8,232,744. MANAGEMENT AND GENERAL EXPENSES 1,040,882. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 9,273,626. FORM 990, PART XI, LINE 9: CAPITAL CONTRIBUTED (TO) FROM SOLE MEMBER 3,445,143. FORM 990, PART XII, LINE 2C: PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. 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